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Intestinal parasites cause significant morbidity and mortality. Diseases caused by Entero-
bius vermicularis, Giardia lamblia, Ar^cylostoma duodenale, Necator americanus, and
Entamoeba histolytica occur in the United States. E. vermicularis, or pinworm, causes irri-
tation and sleep disturbances. Diagnosis can be made using the "cellophane tape test."
Treatment includes mebendazole and household sanitation. Giardia causes nausea, vom-
iting, malabsorption, diarrhea, and weight loss. Stool ova and parasite studies are diag-
nostic. Treatment includes metronidazole. Sewage treatment, proper handwashing, and
consumption of bottled water can be preventive. A. duodenale and N. americanus are
hookworms that cause blood loss, anemia, pica, and wasting. Finding eggs in the feces is
diagnostic. Treatments include albendazole, mebendazole, pyrante! pamoate, iron sup-
plementation, and blood transfusion. Preventive measures include wearing shoes and
treating sewage. E. histolytica can cause intestinal ulcerations, bloody diarrhea, weight
loss, fever, gastrointestinal obstruction, and peritonitis. Amebas can cause abscesses in
the liver that may rupture into the pleural space, peritoneum, or pericardium. Stool and
serologic assays, biopsy, barium studies, and liver imaging have diagnostic merit. Therapy
includes luminal and tissue amebicides to attack both life-cycle stages. Metronidazole,
chloroquine, and aspiration are treatments for liver abscess. Careful sanitation and use of
peeled foods and bottled water are preventive. (Am Fam Physician 2004:69:1161-8. Copy-
right© 2004 American Academy of Family Physicians)
ntestinal parasites cause significant Adult worms are quite small; the males
I
Members of various
family practice depart- morbidity and mortality throughout measure 2 to 5 mm, and the females measure
ments develop articles 8 to 13 mm. The worms live primarily in the
the world, particularly in undeveloped
for "Practical Therapeu-
tics. " This article is or}e countries and in persons with comor- cecum of the large intestine, from which the
in a series coordinated bidities. Intestinal parasites that gravid female migrates at night to lay up to
by the Departmerit of 15,000 eggs on the perineum. The eggs can be
remain prevalent in the United States include
Family Medicine at Enterobius vermicularis, Giardia lamblia, spread by the fecal-oral route to the original
Naval Hospital Jack-
sonville, Jacksonville, Ancyhstoma duodenale, Necator americanus, host and nev^ hosts. Eggs on the host's per-
Fla. Guest editor of and Entamoeba histolytica. ineum can spread to other persons in the
the series is Anthor)y J. house, possibly resulting in an entire family
Viera, LCDR, MC, U5NR.E. vermicularis becoming infected.
E. vermicularis, commonly referred to as the Ingested eggs hatch in the duodenum, and
pinworm or seatworm, is a nematode, or larvae mature during their migration to the
roundworm, with the largest geographic large intestine. Fortunately, most eggs desic-
range of any helminth.' It is the most preva- cate within 72 hours. In the absence of host
lent nematode in the United States. Humans autoinfection, infestation usually lasts only
are the only known host, and about 209 mil- four to six weeks.
lion persons worldwide are infected. More Disease secondary to E. vermicularis is rela-
than 30 percent of children worldwide are tively innocuous, with egg deposition causing
infected.- perineal, perianal, and vaginal irritation.' The
patient's constant itching in an attempt to re-
lieve irritation can lead to potentially debili-
tating sleep disturbance. Rarely, more serious
Pinworm infection should be suspected in children who disease can result, including weight loss, uri-
exhibit pehanal pruritus and nocturnal restlessness. nary tract infection, and appendicitis.'''
Pinworm infection should be suspected in
MARCH 1,2004 / VOLUME 69, NUMBER 5 www.aafp.org/afp AMERICAN FAMILY PHYSICTAN 1161
FIGURE 2. Giardia lamblia cyst.
Reprinted from Centers for Disease Control and Pre-
vention. Accessed November 15, 2003, at http://
phil.cdc.gov.
6. lamhiia
G. lamblia is a pear-shaped, flagellated pro-
tozoan (Figure 2) that causes a wide variety of
gastrointestinal complaints. Giardia is arg-
uably the most common parasite infection of
humans worldwide, and the second most
common in the United States after pin-
worm."-" Between 1992 and 1997, the Centers
for Disease Control and Prevention (CDC)
FIGURE 1. "Cellophane tape test." (Top) Affix estimated that more than 2.5 million cases of
the end of the tape near one end of the slide. giardiasis occur annually."'
Loop the rest of the tape over the end of the Because giardiasis is spread by fecal-oral
slide so the adhesive surface is exposed. (Cen-
ter) Touch the adhesive surface to the perianal contamination, the prevalence is higher in
region several times. (Bottom) Smooth down populations with poor sanitation, close con-
the tape across the surface of the slide. tact, and oral-anal sexual practices. The dis-
ease is commonly water-borne because Giar-
children who exhibit perianal pruritus and dia is resistant to the chlorine levels in normal
nocturnal restlessness. Direct visualization of tap water and survives well in cold mountain
the adult worm or microscopic detection of streams. Because giardiasis frequently infects
eggs confirms the diagnosis, but only 5 per- persons who spend a lot of time camping,
cent uf infected persons have eggs in their backpacking, or hunting, it has gained the
stool. The "cellophane tape test" (Figure I) can nicknames of "backpacker's diarrhea" and
serve as a quick way to clinch the diagnosis."' "beaver fever.""
1162 AMERICAN FAMILY PHYSICIAN wvw.aafp.org/afp VoujME 69, NUMBER 5 / MARCH 1,2004
Intestinal Parasites
MARCH 1,2004 / VOLUME 69, NUMBER 5 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 1163
the "New World" hookworm, is found in the
Americas and the Caribbean, and has recently
been reported in Aft ica, Asia, and the Pacific.
Until the early 1900s, JV. americanus infesta-
tion was endemic in the southern United
States and was only controlled after the wide-
spread use of modern plutnbing and footwear.
Even though the prevalence of these parasites
has drastically decreased in the general popu-
lation, tlie CDC reports that in the United
States, hookworm infection is the second FIGURE 4. Hookworm egg.
most common helminthic infection identified
Reprinted from Centers for Disease Control and Pre-
in stool studies.'" vention. Accessed November 15, 2003, at http://
N. americamts ranges from 10 to 12 mm in phil.cdc.gov.
length for females and 6 to 8 mm for males. It
is distinguished from its slightly larger Euro- the larvae climb the bronchial tree and are
pean cousin by its semilunar dorsal and ventral swallowed with secretions. Six weeks after the
cutting plates at the buccal cavity compared initial infection, mature worms have attached
with A. iiuodenale's two pairs of ventraJ cutting to the wall of t!ie small intestine to feed, and
teeth (Figure 3). The e^s of both worms are 60 egg production begins.
to 70 |jm in length and bounded by an ovoid While larvae occasionally cause prurilic
transparent hyaline membrane; they contain erythema or pulmonary symptoms during
two to eight cell divisions (Figure 4). their migration to the gut,'^ hookworm infec-
Both species share a common life cycle. tion rarely i.s symptomatic until a significant
Eggs hatch into rhabditiform larvae, feed on intestinal worm burden Is established. A tran-
bacteria in soil, and molt into the infective sient gastroenteritis-like syndrome can occur
filariform larvae. Enabled by moist climates because mature worms attach to the intestinal
and poor hygiene, filariform larvae enter their mucosa.
hosts through pores, hair follicles, and even The greatest concern from infection is
intact sldn. Maturing larvae travel through the blood loss. Aided by an organic anticoagulant,
circulation system until they reach alveolar a hookworm consumes about 0.25 mL of host
capillaries. Breaking into lung parenchyma, blood per day. The blood loss caused by hook-
worms can produce a microcytic hypo-
chromic anemia."^ Compensatory volume
expansion contributes to hypoproteinemia,
edema, pica, and wasting. The infection may
result in physical and mental retardation in
children. Eosinophilia has been noted in 30 to
60 percent of infected patients.
While clinical history, hygiene status, and
recent travel to endemic areas can give impor-
tant clues, definitive diagnosis rests on micro-
scopic visualization of eggs in the stool.
FIGURE 3, Electron micrograph of teeth and cutting plate differences
between (left) Ar^cylostoma duodenale and (right) Necator americanus. f. histolytica
Reprinted from Centers for Disease Control and Prevention and Dr. Mae Melvin. Aniebiasis is caused by E. histolytica, a pro-
Accessed November 75, 2003. at http.ilphil.cdcgov. tozoan that is 10 to 60 \jLxn in length and moves
1164 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 69, NUMBER 5 / MARCH 1,2004
Intestinal Parasites
MARCH 1,2004 / VOLUME 69, NUMBER 5 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 1165
Tissue penetration and dissemination are
possible. Trophozoites that penetrate the
intestinal wall spread through the body via the
portal circulation. Amebas are chcmotactic,
attracting neutrophils Ln the circulation. Anie-
bic liver abscesses form because of toxin
release and hepatocyte damage, and usually
develop within five months after infection.
Symptoms of a developing abscess include
fever, dull pleuritic right upper quadrant pain
radiating to the right shoulder, and pleural
effusions. Diarrhea i.s present in only one of
three patients v^^ith abscess. Fever is the pre-
senting symptom in 10 to 15 percent of pa-
tients, and therefore amebic abscess should be FIGURE 6. Computed tomographic scan show-
considered in patients with a lever of un- ing liver abscess.
known origin. Abscesses may rupture into the Reprinted with permission from Medscape. Accessed
pleural space, peritoneum, or pericardium, November 15, 2003. at http://www.med scape.com/
requiring emergency drainage. content/2002/00/44/12/441223/art'iim441223.
1166 AMERICAN FAMILY PKYSICIAN wv^w.aafp.org/afp VOLUME 69, NUMBER 5 / MARCH 1,2004
TABLE 1
Treatment and Prevention of Parasite Infections
Enterobius Primary; Mebendazole (Vermox), 100 mg orally once Treat household contacts.
vermicularis Secondary: Pyranlel pamoate (Pin-Rid), 11 mg per kg Clean bedrooms, bedding.
(maximum of 1 g) orally once;
or
albendazole (Valbazen). 400 mg orally once
If persistent, repeat treatment in two weeks.
Do not give to children younger than two years,
Giardia Adults: Metronidazole (Flagyl), 250 mg orally three times daily for Use proper sewage disposal and water
Iarr)bli3 five to seven days treatment (flocculation, sedimentation,
Pregnant women with miid symptoms: consider defen-ing treatment filtration, and chlorination).
until after delivery. Consume only bottled water in endemic areas.
Pregnant women with severe symptoms: paromomycin (Humatin), Water treatment options:
500 mg oraliy four times daily for seven to 10 days; metronidazole Boil water for one minute
is acceptable. Heat water to 7O''C (158''F) for 10 minutes
Children: albendazole, 400 mg orally for five days Portable camping filter
Asymptomatic carriers in developed countries: treat using regimen Iodine purification tablets for eight hours
for adults or children. Daycare centers:
Asymptomatic carriers in developing countries: not cost-effective Proper disposal of diapers
to treat because of high reinfection rate. Proper and frequent handwashmg
Ancylostoma Albendazole, 400 mg orally once Use proper and continued shoe wear.
duodenale, Mebendazole, 100 mg orally twice daily for three days Use proper sewage disposal.
Necator Pyrantel pamoate, 11 mg per kg (maximum of 1 g) once
americanus Iron supplementation is beneficial even before diagnosis or
treatment initiation-
Packed red blood cells (as needed) can minimize risk of volume
overload in severely hypoproteinemic patients.
Confirm eradication with follow-up stool examination two weeks
after discontinuation of treatment,
Entamoeba Intestinal disease: use both luminal amebicide (for cysts) and tissue Use proper sanitation to eradicate cyst carriage.
histolytica amebicide (for trophozoites} Avoid eating unpeeled fruits and vegetables.
Luminal: Drink bottled water.
lodoquinol (Yodoxin), 650 mg orally three times daily for 20 days Use iodine disinfeaion of nonbottied water.
or
Paromomycin, 500 mg orally three times daily for seven days
or
Diloxanide furoate (Furamide), 500 mg orally three times daily
for 10 days (available from CDC)
Tissue:
Metronidazole, 750 mg orally three times daily for 10 days
Liver abscess:
Metronidazole, 750 mg orally three times daily for five days, then
paromomycin, 500 mg three times daily for seven days
or
Chloroquine (Aralen), 600 mg orally per day for two days, then
200 mg orally per day for two to three weeks (higher relapse rates)
Aspirate if:
Pyogenic abscess is ruled out; there is no response to treatment in
three to five days; rupture is imminent; pericardial spread is imminent
MARCH 1,2004 / VOLUME 69, NUMBER 5 www.aafp.org/afp AMERrcAN FAMILY PHYSICIAN 1167
TABLE 2
Advantages and Disadvantages of Amebicidal Agents
Lumina! amebicides
Paromomycin Seven-day treatment course; may Frequent Gl disturbances; rare ototoxicity and nephrotoxicity; expensive
(Humatin) be useful during pregnancy
lodoquinol (Yodoxin) Inexpensive and effective 20-day treatment course; contains iodine; rare optic neuritis and atrophy
with prolonged use
Diloxanide furoate Alternative to paromomycin if Available in United States only from the CDC; frequent Gl disturbances;
(Furamide) unable to tolerate rare diplopia; contraindicated in pregnant women
For invasive intestinal disease only
Tetracycline, Alternative to metrontdazole Not active for liver abscesses, frequent Gl disturbances; tetracycline should not be
erythromycin (flagyl) if unable to tolerate administered to children or pregnant women: must be used with luminal agent
For invaswe intestinal and extraintestinal amebiasis
Metronidazole Drug of choice for amebic colitis Anorexia, nausea, vomiting, and metallic taste in nearly one third of patients
and liver abscess at dosages used, disutfiram-like reaction with alcohol; rare seizures
Chloroquine (Aralen) Useful oniy for amebic liver Occasional headache, pruritus, nausea, alopecia, and myalgias; rare heart block
abscess and irreversible retinal injury
The opinions and assertions contained herein are veillance—United States, 1992-1997, MMWR CDC
the private views of the authors and are not to be Surveiii Summ 2O00:49(7):1-13,
construed as official or as reflecting the views of 11. DuPont HL, Backer HD. Infectious diarrhea from
the U.S. Navy Medical Corps or the U.S. Navy at wilderness and foreign travel. In: Auerback PS, ed.
Wilderness medicine: management of wilderness
large.
and environmental emergencies. 3d ed. St. Louis:
Mosby, 1995:1028-59.
The authors thank Anthony j. Viera, LCDR. MC, USNR, 12. Giaser C, Lewis P, Wong S, Pet-, animal- and vec-
for constructive feedback and encouragement. tor-borne infeaions. Pediatr Rev 2000:21:219-32
13. Steiger U, Weber M, Ungewbhnliche ursache von
The authors indicate that they do not have any con- erythema nodosum. pleuraerguss und reaktiver
flicts of interest Sources of funding: none reported. arthritis: giardia lamblia. [Unusual etiology of ery-
thema nodosum, pleural effusion and reactive
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